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Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study.

ABSTRACT: BACKGROUND:Globally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care provision and mentorship is necessary both to improve the quality of care and to maximize the impact of mentoring programs. METHODS:In partnership with the Government of Bihar, CARE India and PRONTO International implemented simulation-enhanced mentoring in 320 primary health clinics (PHC) across the state of Bihar, India from 2015 to 2017, within the context of the AMANAT mobile nurse mentoring program. Between June and August 2016, we conducted semi-structured interviews with 20 AMANAT nurse mentors to explore barriers and facilitators to optimal care provision and to implementation of simulation-enhanced mentorship in PHCs in Bihar. Data were analyzed using the thematic content approach. RESULTS:Mentors identified numerous factors affecting care provision and mentorship, many of which were interdependent. Such barriers included human resource shortages, nurse-nurse hierarchy, distance between labor and training rooms, cultural norms, and low skill level and resistance to change among mentees. In contrast, physical resource shortages, doctor-nurse hierarchy, corruption, and violence against providers posed barriers to care provision alone. Facilitators included improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, establishment of strong mentor-mentee relationships, administrative support, and nursing supervision and feedback. CONCLUSIONS:This study has identified many interrelated factors affecting care provision and mentorship in Bihar. The mentoring program was not designed to address several barriers, including resource shortages, facility infrastructure, corruption, and cultural norms. These require government support, community awareness, and other systemic changes. Programs may be adapted to address some barriers beyond knowledge and skill deficiencies, notably hierarchy, violence against providers, and certain cultural taboos. An in-depth understanding of barriers and facilitators is essential to enable the design of targeted interventions to improve maternal and neonatal survival in Bihar and related contexts.

SUBMITTER: Morgan MC

PROVIDER: S-EPMC6202860 | biostudies-other | 2018 Oct

REPOSITORIES: biostudies-other

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Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study.

Morgan Melissa C MC Dyer Jessica J Abril Aranzazu A Christmas Amelia A Mahapatra Tanmay T Das Aritra A Walker Dilys M DM

BMC pregnancy and childbirth 20181025 1

<h4>Background</h4>Globally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care prov ...[more]

PMID: 30359240

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Project description:OBJECTIVES:To assess the provision of basic emergency obstetric and newborn care (BEmONC), knowledge of high-risk pregnancies and referral capacity at health centres in Southern Ethiopia. DESIGN:A facility-based survey, using an abbreviated version of the Averting Maternal Death and Disability needs assessment tool for emergency obstetric and newborn care. Modules included infrastructure, staffing, number of deliveries, maternal and perinatal mortality, BEmONC signal functions, referral capacity and knowledge of risk factors in pregnancy. SETTING:Primary healthcare centres providing delivery services in the Eastern Gurage Zone, a predominantly rural area in Southern Ethiopia. PARTICIPANTS:All 20 health centres in the study area were selected for the assessment. One was excluded, as no delivery services had been provided in the 12 months prior to the study. RESULTS:Three out of 19 health centres met the government's staffing norm. In the 12 months prior to the survey, 10?004 ([Formula: see text]) deliveries were attended to at the health centres, but none had provided all seven BEmONC signal functions in the three?months prior to the survey ([Formula: see text]). Eight maternal and 32 perinatal deaths occurred. Most health centres had performed administration of parenteral uterotonics (17/89.5%), manual removal of placenta (17/89.5%) and neonatal resuscitation (17/89.5%), while few had performed assisted vaginal delivery (3/15.8%) or administration of parenteral anticonvulsants (1/5.3%). Reasons mentioned for non-performance were lack of patients with appropriate indications, lack of training and supply problems. Health workers mentioned on average 3.9±1.4 of 11 risk factors for adverse pregnancy outcomes. Five ambulances were available in the zone. CONCLUSION:BEmONC provision is not guaranteed to women giving birth in health centres in Southern Ethiopia. Since the government aims to increase facility deliveries, investments in capacity at health centres are urgently needed.

Project description:BACKGROUND:Nearly 15% of all pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labor, and complications of abortion. Between 1990 and 2015, an estimated 10.7 million women died due to obstetric complications. Almost all of these deaths (99%) happened in developing countries, and 66% of maternal deaths were attributed to sub-Saharan Africa. The majority of cases of maternal mortalities can be prevented through provision of evidence-based potentially life-saving signal functions of emergency obstetric care. However, different factors can hinder women's ability to access and use emergency obstetric services in sub-Saharan Africa. Therefore, the aim of this review is to synthesize current evidence on barriers to accessing and utilizing emergency obstetric care in sub-Saharan African. Decision-makers and policy formulators will use evidence generated from this review in improving maternal healthcare particularly the emergency obstetric care. METHODS:Electronic databases including MEDLINE, CINAHL, Embase, and Maternity and Infant Care will be searched for studies using predefined search terms. Articles published in English language between 2010 and 2017 with quantitative and qualitative design will be included. The identified papers will be assessed for meeting eligibility criteria. First, the articles will be screened by examining their titles and abstracts. Then, two reviewers will review the full text of the selected articles independently. Two reviewers using a standard data extraction format will undertake data extraction from the retained studies. The quality of the included papers will be assessed using the mixed methods appraisal tool. Results from the eligible studies will be qualitatively synthesized using the narrative synthesis approach and reported using the three delays model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be employed to present the findings. DISCUSSION:This systematic review will present a detailed synthesis of the evidence for barriers to access and utilization of emergency obstetric care in sub-Saharan Africa over the last 7 years. This systematic review is expected to provide clear information that can help in designing maternal health policy and interventions particularly in emergency obstetric care in sub-Saharan Africa where maternal mortality remains high. SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42017074102 .

Project description:BackgroundNearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa.MethodsArticles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings.ResultThe search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff.ConclusionsA number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.Systematic review registrationPROSPERO CRD42017074102.

Project description:BackgroundSignal functions for emergency obstetric and newborn care (EmONC) are the major interventions for averting maternal and neonatal mortalities. Readiness of the facilities is essential to provide all the basic and comprehensive signal functions for EmONC to ensure emergency services from the designated facilities. The study assessed population coverage and availability of EmONC services in public and private facilities in Bangladesh.MethodsAn assessment was conducted in all the public and private facilities providing obstetric care in to in-patients 24 districts. Data were collected on the performance of signal functions for EmONC from the study facilities in the last three months prior to the date of assessment. Trained data-collectors interviewed the facility managers and key service providers, along with review of records, using contextualized tools. Population coverage of signal functions was assessed by estimating the number of facilities providing the signal functions for EmONC compared to the United Nations requirements. Availability was assessed in terms of the proportion of facilities providing the services by type of facilities and by district.ResultsCaesarean section (CS) delivery and blood transfusion (BT) services (the two major components of comprehensive EmONC) were respectively available in 6.4 (0.9 public and 5.5 private) and 5.6 (1.3 public and 4.3 private) facilities per 500,000 population. The signal functions for basic EmONC, except two (parental anticonvulsants and assisted vaginal delivery), were available in a minimum of 5 facilities (public and private sectors combined) per 500,000 population. A major inter-district variation in the availability of signal functions was observed in each public- and private-sector facility. Among the various types of facilities, only the public medical college hospitals had all the signal functions. The situation was poor in other public facilities at the district and sub-district levels as well as in private facilities.ConclusionsIn the public sector, CS delivery and BT services were available in the minimum required number of facilities. However, to ensure basic EmONC services, participation of the private sector is necessary. Public-private partnership should be promoted for nationwide coverage of signal functions for EmONC in Bangladesh.

Project description:BackgroundSince 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa.MethodsThis review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies.ResultsOne hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships.ConclusionDespite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women.Systematic review registrationPROSPERO 2014 CRD42014015549.

Project description:BackgroundAlthough safe motherhood strategies recommend that women seek timely care from health facilities for obstetric complications, few studies have described facility availability of emergency obstetric care (EmOC). We sought to describe and compare availability and readiness to provide EmOC among public and private health facilities commonly visited for pregnancy-related complications in two districts of northwest Bangladesh. We also described aspects of financial and geographic access to healthcare and key constraints to EmOC provision.MethodsUsing data from a large population-based community trial, we identified and surveyed the 14 health facilities (7 public, 7 private) most frequently visited for obstetric complications and near misses as reported by women. Availability of EmOC was based on provision of medical services, assessed through clinician interviews and record review. Levels of EmOC availability were defined as basic or comprehensive. Readiness for EmOC provision was based on scores in four categories: staffing, equipment, laboratory capacity, and medicines. Readiness scores were calculated using unweighted averages. Costs of C-section procedures and geographic locations of facilities were described. Textual analysis was used to identify key constraints.ResultsThe seven surveyed private facilities offered comprehensive EmOC compared to four of the seven public facilities. With 100% representing full readiness, mean EmOC readiness was 81% (range: 63%-91%) among surveyed private facilities compared to 67% (range: 48%-91%) in public facilities (p = 0.040). Surveyed public clinics had low scores on staffing and laboratory capacity (69%; 50%). The mean cost of the C-section procedure in private clinics was $77 (standard deviation: $16) and free in public facilities. The public sub-district facilities were the only facilities located in rural areas, with none providing comprehensive EmOC. Shortages in specialized staff were listed as the main barrier to EmOC provision in public facilities.ConclusionsAlthough EmOC availability and readiness was higher among the surveyed seven most commonly visited private clinics, public facilities appeared to be more affordable for C-section and more geographically accessible. Strategies to retain anesthesiologists and surgeons, such as non-financial incentives, are needed to improve EmOC provision in the public sector. Centralized blood banks are recommended to streamline safe blood acquisition for obstetric surgeries.

Project description:ObjectiveThe COVID-19 pandemic has highlighted ongoing challenges to optimal supportive end-of-life care for adults living in long-term care (LTC) facilities. A supportive end-of-life care approach emphasises family involvement, optimal symptom control, multidisciplinary team collaboration and death and bereavement support services for residents and families. Community-based and palliative care specialist physicians who visit residents in LTC facilities play an important role in supportive end-of-life care. Yet, perspectives, experiences and perceptions of these physicians remain unknown. The objective of this study was to explore barriers and facilitators to optimal supportive end-of-life palliative care in LTC through the experiences and perceptions of community-based and palliative specialist physicians who visit LTC facilities.DesignQualitative study using semi-structured interviews, basic qualitative description and directed content analysis using the COM-B (capability, opportunity, motivation - behaviour) theoretical framework.SettingResidential long-term care.Participants23 physicians who visit LTC facilities from across Alberta, Canada, including both in urban and rural settings of whom 18 were community-based physicians and 5 were specialist palliative care physicians.ResultsMotivation barriers include families' lack of frailty knowledge, unrealistic expectations and emotional reactions to grief and uncertainty. Capability barriers include lack of symptom assessment tools, as well as palliative care knowledge, training and mentorship. Physical and social design barriers include lack of dedicated spaces for death and bereavement, inadequate staff, and mental health and spiritual services of insufficient scope for the population.ConclusionFindings reveal that validating families' concerns, having appropriate symptom assessment tools, providing mentorship in palliative care and adapting the physical and social environment to support dying and grieving with dignity facilitates supportive, end-of-life care within LTC.

Dataset Information

Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study.

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Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study.

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